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HomeMy WebLinkAbout01-5384IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA Brenda Brownewell, individually and as parent and natural guardian of Amber Brownewell, a minor 216 Hill Street Mt. Holly Springs, PA 17065 Plaintiffs Allen Stutenroth 551 Summit Drive Carlisle, PA 17013 Defendant C/vii Action - Law Jury Tr/al Demanded PRAECIPE FOR WRIT OF SUMMONS TO THE PROTHONOTARY OF SAID COURT: Please issue A Writ of Summons in the above-captioned action. X A Writ of Summons shall be issued and forwarded to ( )Attomey ( X ) Sheriff Scott B. Cooper, Esquire /9chmidt, Ronea 8s Kramer, P.C. 209 State Street Harrisburg, PA 17101 (717) 232-6300 Date: Signature of Attorney Supreme Court I.D. No. 70242 WRIT OF SUMMONS TO THE ABOVE NAMED DEFENDANT: YOU ARE NOTIFIED THAT THE ABOVE-NAMED PLAINTIFFS HAVE COMMENCED AN ACTION AGAINST YOU. Date:~~2~J_ Prothonotary / Deputy ( ) Check here if reverse is issued for additional information IN THE COURT OF COMMON PLEAS CUMBERLAND COUNT'/', PENNSYLVANIA Brenda Brownewell, individually and as parent and natural guardian of Amber Brownewell, a minor 216 Hill Street Mt. Holly Springs, PA 17055 Plaintiffs Allen Stutenroth 551 Summit Drive Carlisle, PA 17013 Defendant Civil Action - Law No. 2001 Jury Trial Demanded INSTRUCTIONS TO CUMBERLAND COUNTY SHERIFF NO. CUMBERLAND COUNTY Please serve the Writ of Summons on the Defendant listed below at the address listed and in the manner indicated. Allen Stutenroth 551 Summit Drive Carlisle, PA 17013 Serv/ce by Cumberlo. nd County Sher~ If you have any questions, please contact Tammie at (717) 232-6300. Thank youl sHERIFF'S RETURN - REGULAR CASE NO: 2001-05384 P COMMONWEALTH OF PENNSYLVAIqIA: coUNTY OF cUMBERLAND BRoWNEWELL BRENDA E__~TAL~ VS sTUTENROT___HALL____EN---- ~ -- - sheriff or Deputy Sheriff of KENNETH GQ~s~RT ' Cumberland county,pennsylvania, who being duly sworn according to law, was served upon , - ~ ~ ~ the says the within wRIT OF sUMMONS~___ STUTENROTH ALLEN 2001 DEFEND_ANT__ ~' at ~535__~:0~ HOURS, on the 19___t~ day of Se_e_~_~ember, at 5__51_sUMMIT DRIVE by handing to CARLISLE, PA 17013 ANN STUT~NRO_TH, WIFE together with a true and attested copy of WRIT O__F suMMONS ~ ~ and at the same time directing He~ attention to the contents thereof. sheriff's CostS: 18.00 Docketing 3.25 Service .00 Affidavit 10.00 Surcharge .00 _ Sworn and Subscribed to before me this ~g~ _ day of So AnswerS: ~ T~-ne 09/20/2001 sCHMIDT RONCA & KRAMER By:~ _ Brenda Brownewell, individually as parent and Natural Guardian of Amber Brownewell, a Minor Allen Stutenroth, Plaintiffs, Defendant. IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA CIVIL ACTION- LAW NO. 01-5384 JURY TRIAL DEMANDED PRAECIPE FOR ENTRY OF APPEARANCE To the Prothonotary: Kindly enter my appearance on behalf of the Defendant, Allen Stutenroth in the above- captioned matter. Date: October I0, 2001 Respectfully submitted, LAW OFFICES OF ANN WALDHERR Hillside Corporate Center 5001 Louise Drive, Second Floor Mechanicsburg, PA 17055 Attorney for Defendant Allen Stutenroth CERTIFICATE OF SERVICE I, John C. Swartz, Jr., Esquire, hereby certify that I have this 10 th day of October 2001, caused to be served via first class United States Mail, postage prepaid, a true and correct copy of the foregoing pleading upon the following: Scott B. Cooper, Esquire 209 State Street Harrisburg, PA 17101 IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA Brenda Brownewell, individually and as parent and natural guardian of Amber Brownewell, a minor Allen 8tutenroth Plaintiffs Defendant. Civil Action - Law No: 01-5384 PETITION FOR APPROVAL OF COMPROMISE SETTLEMENT AND DISTRIBUTION OF PROCEEDS FOR AMBER BROWNEWELL, A MINOR AND NOW, comes the Petitioner, Brenda Brownewell, as the Parent and Natural Guardian of Amber Brownewell, a minor, and respectfully avers as follows: 1. The Petitioner, Brenda Brownewell, is the Parent and Natural Guardian of Amber Brownewell, a minor, both currently residing at 61 Partridge Circle, Carlisle, PA. 2. The Petitioner's daughter, Amber Brownewell, is a minor, date of birth, April 24, 1987, who resides with her at the above mentioned address. 3. On October 19, 1999, Petitioner's minor, Amber Brownewe11, was injured in an automobile accident caused by the driver of another vehicle, Allen Stutenroth, which collided with her vehicle. {See Police Report attached hereto as Exhibit "A'). 4. The motor vehicle collision took place on October 19, 1999 at the intersection of east Pomfret Street and south Hanow~r Street in the Borough of Carlisle, Cumberland County, Pennsylvania. Mr. Stutenroth traveled through a red light, colliding with Brenda Brownewell's vehicle. 5. As a direct and proximate result of the collision, Amber Brownewell, suffered left rib pain and back pain. (See records of Carlisle Hospital at Exhibit "B'). 6. The Petitioner has reached a compromise with Kemper Insurance Company, the insurer for Allen Stutenroth, regarding a claim for injuries sustained by Amber Brownewell in the form of a lump sum of One Thousand Dollars ($1,000.00) in full settiement of the minor's claim. 7. The Petitioner is satisfied that the offer of settlement is just and reasonable and is willing to accept said offer, if approved by the Court. (See joinder attached as Exhibit "C'). 8. In pursuing claims against Allan Stutenroth, Petitioner engaged the law firm of Schmidt, Ronca & Kramer, P.C., under a Contingent Fee Agreement, that the said law firm should be paid 30'% of a settlement obtained prior to filing suit. (See Contingency Fee Agreement attached hereto as Exhibit "D"). 9. Petitioner's attorneys have agreed to reduce their fee to 25% in the settlement of the claims of Brenda Brownewell and l~ave agreed to deduct no fee from the settlement of the minor, Amber Brownewell. 10. Schmidt, Ronca & Kramer, P.C., has incurred costs relevant to obtaining copies of medical records. However, all costs were taken from the settlement of Brenda Brownewell and it was agreed that no costs would be taken from the settlement of the minor. 11. The Petitioner requests that the Court distribute the present payment of $1,000.00 to be paid in settlement of Amber Brownewell claims as follows: To Brenda Brownewell, As the Parent And Natural Guardian Of Amber Brownewell, a Minor $1,000.000 Total: $1~000.00 12. The Petitioner requests that this payment be authorized without formal appointment of a Guardian of the mi:nor, or the Entry of Security, with the Petitioner, Brenda Brownewell, being authorized and directed to invest the funds belonging to Amber Brownewell, a minor, as follows: To invest said sums in a Savings Account with Members 1st Federal Credit Union, 5000 Louise Drive, Mechanicsburg, PA 17055, each Account not to exceed such sums as are fully insured with F.D.I.C. and/or; To invest said sums in a Certificate of Deposit Members 1st Federal Credit Union, 5000 Louise Drive, Mechanicsburg, PA 17055, each Certificate not to exceed such sums as are fully insured with F.D.I.C. 13. The Savings Account and/or Certificate of Deposit opened on behalf of Amber Brownewell as a result of the anticipated settlement shall be marked as follows: A. This money shall be held in trust not to be redeemed withdrawn, negotiated, or any way alienated except for the renewal in its entirety until the age of majority of the minor, Amber Brownewell, which is April 24, 2005, except by order of this Court. 14. Based on the above, the Petitioner approves of this petition and requests this Honorable Court to issue an order allowing the Petitioner to execute the Release attached hereto as Exhibit "E'. WHEREFORE, the Petitioner, Amber Brownewell, requests this Honorable Court enter an order approving the foregoing Compromise Settlement directing the distribution of proceeds to the Petitioner as set forth herein. I A?E: -'/'fie 9' By: Respectfully sulbmitted, $chmidt, Ronca/h Kramer, P.C. Scott B. Cooper, Esquire 209 State Street Harrisburg, PA 17101 (717) 232-6300 Attorney I.D. #70242 Attorney for Petitioner ~××)REPER TO OVERLY S.EETS COMMONWEAL TH OF PENNSYLVANIA POLICE AC_C_C~IDENT REPORT REPORTABLE ~. NON-REPORTABLE [~ PENNDOT USE ONLY ACCIDENT LOCATION POLICE INFORMATION INCIDENT NUMBER ?q , NAME ~_..,~'~.~' 'J ~/~ 3. STATIONI 4. PATROL 5. {NVESTIGA BADGE 6. ~PRO Y BADGE 7. INVES 8. ARRIVAL 9. ACCIDENT 18. HAZARDOUS MATERIALS Y [] N [] 10. DAY OF. K 12. NUMBER ° 15. PRIV. PROP. ACCIDENT YE~ N[~ VEHICLE OAMAGE 0 - NONE UNiT 1 - UGHT 2 - MODERATE 3 . SEVERE UNIT Ig. PENNDOT PROPERTY Y [] N [] UNIT# 1 36. LEGALLY Y N 37. REG. 39~ PA TITLE OR OUT'OF-STATE YIN PRINCIPAL RIOADWA Y INFOR/VIA TION 23, SPEED 24 TYPE ~iACCESS L,M,T I H,GHWAY .'¢' i 00.TROL INTERS~F_~CTING ROAD: 2_6~ ROUTE NO. OR ~TREETNA.E ZF~ ~¢'~r ? 27 SPEED LIMIT IF NOT AT INTERSECT/ON: 30, CROSS STREET OR ,.. SEGMENT MARKER 31. DIRECTION I'~'~ DISTANCE PROM SITE ~J © ~' ~) E WI FROM SITE 33. DISTANCE WAS CONSTRUCTION 13~, TRAFFIC PRINCIPAL UNIT # 2 Y N 37. REG. lin ADDRESS · 42. CITY, STATE & ZIPCODE 45. MODEL - (NOT 46. )VEHICLE 56. DRIVER NUMBER 58. DRIVER NAME & ZlPCODE 62. DATE OF BIRTH 65. DRIVER yrm 67. CARRIER ~.CARRIER ADDRESS 69. CITY, STATE VEHICLE 66.0RIVER i41,OWNER ADDRESS 42. CITY. STATE & ~PCODE N [] UNK [] BODY TYPE) UNK [] v~.,CLE I BODY Og ,SPEC'AL ! VE"ICLE ¢'q 56. DRIVER NUMBER 58, DRIVER NAME 59. DRIVER ADDRESS ~0. CITY. STATE & 23PCODE · DATE OF BIRTH 64. COMM. VEH. 65. DRIVER y ~1 CLASS 67. CARRIER & ZIPCODE ,o. iicD CONFIG~'""-- ODY TYPE ~ ' '~5. NO. OF ~. HAZARDOUS 77. REL SE OF AZ MAT AXLES ' MATERIALS ~ YI'~ N ~UNK ~] A..,-,~,,,,~, ~804~85 69. CITY, STATE & ZiPCOOE DRIVER ~. VER. 7~1. CARGO' ebON,,,,.,. ""~oDYTYRE .... 75. NO. O~=............ 76. HAZARDOUS 77 RE SE P H MAT ~LEsP~MATERIALB -- ' V'¢ ACCIDENT DATE: /~ B C D ~ F G NAME ADDRESS H I J K L M ROAD SURFACE : : (IF APPLICABL~ ~. DESCRIPTION OF OA~GED PROPER~ : 87. NAR~TIVE - iDEN~ PREClPiTA~NG ~EN~, CAUSA~ON FACTORS. SEQUENCES OF ~ENTS, WITNESS ST~MENTS, AND PROVIDE A001~ONAL D~LS LIKE INSURANCS [~ORMA~ON ANO L~A~ON OF T~ED VEHICLES [F KNOWN, I~FOR~TION INFORMATION 88. WITNESSES NAME ADDRESS PHONE Bg. VlO~TIONS INDICATED ~. SECTION NUMBERS (ONLY IF CHARGED) TC NTC  REFUSE 0/o~ REFUSE COMP TE? UNIT 1 0. 0~ ~ UNK ~ UNK YES NO 1804185 NONE NAME / ADDRESS / PHONE / AGE / SEX / RACE / M.S. BRO#NENELL, AMBER 216 HILL ST (717)486-8775 12Y F N S 04/24/87 210-66-1363 CONVENIENT CARE/EMERGENCY REGISTRATIOH PA / / PA GAME CONNISSTON HARRISBURG,, PA BROMNENELL~ BRENDA (717)486-9775 MT HOLLY SPR[NOS~ PA17065 "~E~^O~"ESS'".O.~/RE~=O.~ODa~SOC.SEC..O (717)486--8775 BRONNEMELL~ BRENDA K. 216 HILL ST 168-64-3289 MT HOLLY SPRINGS~ PA170G5 ERIE INSURANCE GROUP 75 BLUE CROSS 361 43 YWH168643289 C140650 BRONNEWELL ~ AMBER O1 INSURANCE COMMENT NVA TO BE EVAL BRONNENEL. L.~ BRENDA k. ' 03 AUTO ERIE KEYSTONE / ANTHONY 0 ISOLATION ALERT N BRIEF VISIT 26700 CLASS I VISIT 26710 CLASS II VISIT CLASS III VISIT 26730 CLASS IV VISIT 26740 CLASS V VISIT 26750 MINOR SUTURE EDS 01 MEDIUM SUTURE EDS 02 MAJOR SUTURE INTUBATION EDS I IV SET UP EDS 06 PELVIC EXAM EDS 14 NITRO SET-UP EDS 16 CAST, SCOTCH SHORT ARM 260: CAST. SCOTCH LONG ARM CAST, SCOTCH SHORT LEG 26033 CAST, SCOTCH LONG LEG 26034 CAST ROLL, PLASTER B/P MONITOR 26037 PACER PADS 79064 GASTRO/HEMO SLIDE 26060 KIDDE TOURNIQUET 26041 OCL PER FOOT 79670 F.S.B.S. 80081 TUBE GAUZE PER FOOT 26074 ED STAT ESTA1 PULSE OX POXED EXTENDED CHARGE I 26760 EXTENDED CHARGE II 2677 '~ALL ADDITIONAL CHARGES NAME: BROWNEWELL, AMBER MRN: 640810 DOS: 10/19/1999 CHIEF COMPLAINT: MOTOR VEHICLE ACCIDENT. HPI: This is a 12-year-old female who was the front seat passenger, seat belted, in a head on collision. The child got out of the car, walked around, had no pain. She had delayed onset of some discomfort in the left rib cage area when she takes a deep breath or moves. No shortness of breath. PMH: None. PHYSICAL EXAMINATION: GENERAL: Alert, oriented female. Temperature 37.0, pulse 76, respirations 16, blood pressure 130/60. She is not producing any stridor. There is no accessory muscle use to breathe. She seems comfortable. She has no tracheal deviation. LUNGS: Clear to auscultation, bilaterally. HEART: Regular rate and rhythm, no murmur. ABDOMEN: Soft and nontender. She does have some minor pain on palpation in the mid axillary line, left fourth and fifth rib area. No bony deformity on palpation. LABS/XRAY: X-ray of left rib series per ED&B interpretation negative. DIAGNOSIS-. CHEST WALL CONTUSION. PLAN: For this musculoskeletal injury, advised ice, Tylenol or Advil. PAUL FP~LNKE, M.D. D 2301 EST T.t407 EST/798/38576 10/19/1999 10/20/1999 CARLISLE HOSPITAL EMERGENCY DEPARTMENT RECORD CARLISLE HOSPITAL 246 PARKER STREET CARLISLE, PA 17013-0310 CONVENIENT CARE/EMERGENCY REGISTRATION FOR NURSING ASSESSMENT SEE NURSING DOCUMENTATION SHEET ROS: SH: PMH: FH: ~ //~0 INTERPRETATION OF: , / DISPOSITION FROM~ ED ~ ~[C~NTER ~SO~ ~o~ ws~m ~ ~S ~NS NOTIFIED TIME INIT. RESPONDED MVA TO BE EViL 95~97 __ 0521906 8EONNENELL, ~HBE~ A. 10/19/99 2[:47 12Y ER-0508 [REV 6/991 = TREATMENT IN PROGRESS ON ARRIVAL: [] CPR DownTime [] Airway- [] Oral I"'1 Nasal- Size. [] Airway, Endotracheal - Size [] A rway, Nasotracheal - Size [] IV- Sotution Site Saline Lock Site_ Size Pupils: [] N/A Right - Size Reaction Left- Size Reaction = INITIAL NURSING REVIEW: REASON FOR VISIT; [~RAUMA PAST MEDICAL HISTORY Size Pupil Sizes: 1. 40 20 50 [] MEDICAL [] Monitor- Rhythm Rate [] Oxygen- [] Mask, [] NC- L/Min [] Spinal Immobilization [] Mast [] Pressure Dressing [] Other Visual Activity: OD OS [] N/A [] With Glasses ,.~ Without Glasses [] PSYCHOSOCIAL/EMOTIONAL Extremities: [] Laceration [] Deformity [] Abrasion [] MAE LMP: Weight: DRUGS: Vital Signs: POX: [] N/A POX: SAFETY: Are you or have you ever been afraid or your safety in your home? [] Yes [] No PATIENT PROBLEM: Nursing Diagnos~s Coping, Ineffective Airway Clearance, Ineffective Fluid Volume, Alterations in: Anxiety __ Gas Exchange. Impaired Breathing Patterns, Ineffective __ Hyperthermia (Fever) Cardiac Output, Decreased __ Infection, Potential '~ Comfort, Alterations in: .__Injury, Potentia~ Communication Impaired ~ Knowledge, Deficit OUtCOME/GOAL: F_~ected by aischa[ge:t ~ ~A) ,0~.-.~ Clothing Jewelry Other NURSES __ Mobility, Impaired __ Noncompliance __ Setf Care Deficit __ Skin Integrity, Impaired __ Thought Process, Alt. in: --Tissue Peffusien, Alt. in: NURSE'S SIGNATURE PLAN OF CARE: [] Maintain Patient Airway [] Monitor Cardiovascular Status [] IV [] BP Monitor [] EKG [] Cardiac Monitor [] Safety Measures [] Restraints [] Suicide Precautions [] Seizure Precautions [] Side Rails Up ~ Comfort Measures [] Pain Control [] Position for Comfort '~ Prepare for Exam ~ Explain Procedures -~ Emotional Support Patient Teaching Discharge Instructions Other Other Carlisle Hospital and Health Services NURSING DOCUMENTATION SIGNATURE = MEDICATIONS [] IV D, Cd w~th ca he er ntac TREATMENT / PROCEDURE TIMES IV TOTAL = []TIMERESP' TREATMENT_TiME PO Urine TIME TIME [] AIRWAY - TYPE TIME -- SiZE [] NASOGASTRIC TUSE SIZE __ TIME__ SITE AMT IN AMT OUT.__ TOTAL TOTAL [] FOLEY SIZE TIME COLOR = INTAKE: Other TOTAL = NOTIFICATION OF: [] Hospital Social Worker. [] Family Doctor [] Family [] Coroner [] Police [] Consultant [] Crisis intervention.. [] Other [] O2 @ VIA TOTAL = OUTPUT: [] Nursing Home__ Bp MONITOR I TIMES: EKG CXR LABS DRAWN UA ARG [] PULSE OX VITAL SIGNS ON Time BP P R NOTES: / DISPOSITION: ~RG~: ~I~EN INSTRUCTIONS GIVEN ~ Admitted ~o: ~ Self ~ Computer [] For Observation to: [] Transferred ~o: [] Wheelchair [] Ambulance [] Morgue [] Monitored Litter  [] Other [] Litter [] Carried ,.~'~amily .,,.l~]~m b ulatory [] Friend [] Arnbulatory with Assistance [] Police [] Valuables [] Other fNURSES SIGNATURE Likes to be called Escort Room #..,~:~__~ Ht ., .~Wt Present ~.,. Usual. Vital Si~s: T ~[ P '1~ R /~7 BP [9~/'~1i0('} -- ~aO2 ' ~ Head,irc ALL~ITIVI~ ~e r~gcJion) Medication ~.)fl/~fflqt~ [4Jl~ [/l - I'll V~'k Food hq. ~ It~ Environm~ntnl (latex, tape) /A LO/1 .t.~. Exposure to Infectious Disease [] Yes [] No If yes, iis~ Immunizations Current U Yes [] No [] N/A Comments []N/A ~ N/A C N/A TETANUS STATUS: E Within 5 yrs ~5-10 yrs []More thaa 10 yrs [] Unknown [] N/A CURRENT MEDICATIONS: (Rx, OTC, Herbs, Vitamins) Med Dose Last Duse/Time 1. 3. 10. MEDICATIONS: [] None [] Home [] To Pharmacy E ~ Bedside HABITS: TOBACCO USE ALCOHOL INTAKE 7s,~ever Smoked [] Chew r' Snuff C. Sqone [] Ex Smoker (Date Stopped ) [] Occasional [] Smokes (Pant per day) [] Daily (Amt STREET DRUGS [] Yes [] No Type(s) MENTAL STATUS: Mo~d/Affect: Thought: , %~Appropriate L~lear/ D Blunted/Flat Spontaneous [] Defensive U Vague/ [] Apprehensive Disconnected Z Restless/ U Disoriented Combative ~ Crying Memory: Speech: ~q~Ilact LM~Srmal/Clear [] Impaired [] Silent [] Recent [] Talkative [] Distant Past [] Repetitive ~ Mumbling [] Slow to answer Language Barrier? Yes No It, yes, language spoken: ~ReSE: RESP: gular ~ Irregular E Normal [] Wheeze [] Rapid Z Full/ E Weak ~ Shallow [] Labored D Stridor Bounding [] Deep D Retractions ~¢9~LOR: ~. Nolmal ~lushed E Dusky C Cyanosis [] Pale [] Jaundiced [] Nailbeds [] Circumoral ~Other S IN: S~lSYVarm 5 Cool E Rash [] Ecchymosis Z~"Dry [] Clammy Gf~dema ~ Other LUNG SOUNDS: Right: /{3 Clear [] Crackles U Rhonchi [] N/A ' [] Diminished •Wheeze [] Absent Left: /g(Clear ~ Crackles [] Rhonchi ~ Diminished [] Wheeze g Absent PATIENT ASSESSMENT FORM ~o o~to^ (~,~ ~r) Carlisle Hospital Triage Status: Mode of Arrival: Accompanied By: ~ Priority I •~LS U BLS 2.Police 2 Friend E ~iofi~ II ~bulato~ ~P~ent ~ F~ily ffPfiofirj III U ~eelchak E Self ~ O~ E N/A E C~ed U S~etcher , R o r visit Treatment prior to arrival PAIN: ~ Denies U N/A Severity 012345678910 [] Constant [] ~ull ~ Radiating [] Intermittent i~.~htarp /~Burnj/i~ E Other Triage/Signature:~[tkatXna, mO,l~ D PREVIOUS SURGERy: [] N/A [] N/A Implantable Devices: [] Yes _Z No If yes, explain Other Devices: MEDICAL HISTORY/PSYCHIATRIC HISTORY: E N/A [] Seizures [] Liver Disease C Pregnant ~ Hypertension [],Bleeding Tendencies LMP [] Cardiac Disease [] C¥& ~ Depression U Chest Pain, . K214.~;l/rl~s [] Anxiety [] MI A~ JJ ~ z Transfusion [] Ulcer U~/' [] Emphysema Reaction G CA [] COPD ~Yes [] No [] Kidney Disease [] Home'Oxygen ~ Other: [] Diabetes [] Cough U Glaucoma · [] Dyspnea FAMILY ~IIS~R~'~ [] Diabetes E Hypert~b_~ ~l.~p~' [] Other Cardiac Disease N/A LEARNING & t2OMMUNICATION: How do you best learn? •Writing[]Visual •Read []Demonstration Whom do we teanh? [] Patient E Other Barriers to learning? [] Yes E No Cultural/Religion Needs:• Yes r- No Dentures: •Upper []Lower •None Brought to hospital?[]YesF~o Vision:EGlasses[]ContactsENone Brought to hospital? []Yes[~4~o Sight: [] Blind ~,2 Diminished Hear,rog Atd.,_Rt[~Lt~3Both' '~- ' ~None' l}r, pught t Hear,ng: [] Deaf .~/.~/l~i~i~/.]~lT~t /,/~ /I // lin SIGNATUILE: /~ Reviewing RN: ~ Copy to Pharmacy PATIENT IDENTIFICATION Carlisle Hospita,DEPARTM~,qT OF RADIOLOGY and Health Services 246 Parker Street * P,O, Box 310 * Carlisle, Pennsylvania 17013-0310 * (717) 249-1212 CARLISLE IMAGING ASSOCIATES, BROWNEWELL, AMBER A. 12Y 216 HILL ST MT HOLLY SPGS, PA 17065 P.e. 10/19/1999 X-RAY #135754 MED. REC. #640810 DR. GUARRACINO - ER LEFT RIBS WITH CHEST No fracture or other bony abnormality is noted in the visualized portions of the left ribs. No pleural effusion, pneumothorax or pulmonary contusion is noted. IMPRESSION: Negative left ribs. JDT/pl T: 10/20/1999 09:12 am TAGGART, M.D. Carlisle Hospital -- Emergency Departm BRO EWELL AMBER 246 Parker St. Carlisle, PA 17013 --(717~ -45-5500 DISPOSITION SUMMARY Patient: BROWNEWELL AMBER SS #: CURRENT Address: City: Arrival: 10/19/99 10:50pm MD ED: Paul Franke, M.D. Res/PNNP: Dx #1: Chest Wall Contusion Current Ph: _ Zip: Disch: 10/19/99 11:04pm PMD: PMD Ph: lCD-9 #1:922.1 #1 Dx Engk CONTUS.ESW Rx #1: Tylenol (Acetaminophen) 325 mq 1 or 2 capsules by mouth every 4 to 6 hours as needed #50 capsules Follow-up: EMERGENCY DEPARTMENT E/D CARLISLE HOSPITAL Age/DOB: __ Medical Record: 640810 Disposition: #1 Dx Span: CONTUS.SSW Rx~l Printed: 10/19/99 11:04pm CARLISLE, PA F/U MD Ph: 717~245-5500 FlU D/T: Other Instr: ICE, IBUPROFEN OR TYLENOL AS DIRECTED. RETURN TO ER IF SHORT OF BREATH. MY SIGNATURE BELOW INDICATES: > I have received and understood the oral instructions regarding my current medical problem. > I will arrange follow-up care as instructed above. > I acknowledge receipt of the written instructions as outlined on th~ and any prev/~./~P~ .a/g.2(s~ill r~ an/~ review these instructi/¢~ i // t (or Legal Guar~lJa~) Signature StaflZ(/~it~e~s) Signature Carlisle Hospital and Health Services PAT'ENT'$ NAME: (~/~4~) ~ .~')~"~ ~-...~ INSURANCE CO.: ~ Statement to Permit the Release of Medical Information and Payment of Medicare and/or Other Health Insurance Benefits and/or Physician. I authorize Carlisle Hospital as the holder of medical information pertaining to me to release the necessary and appropriate medical information to the fiscal im:ermediary of the SociaI Security Administration and/or to my primary or supplemental health insuranee company or its designated review agency for payment for services rendered. I authorize the Carlisle Hospital's and/or the physician's billing agent to submit a claim to Medicare or other health insurance on my behalf, or to request, on a ,one time only basis, from the Social Security Administration, such information necessary to complete the claim submission process. I am the indivkiual to whom the information/record pertains, or am authorized to consent, on behalf of the individual, to the release of the information/record. I un.derstand that any false statement or representation knowingly and wilfully made or caused to be made for use in determining rights to Medicare benefits or payments may be punishable by a fine of not more than $10,000.00 or one year in prison, or both. I request that payment of authori'zed benefits be made on my behalf. I assign the payment of inpatient or outpatient hospital be~tefits to Carlisle Hospital for those services provided by Carlisle Hospital and/or I assign the benefit payable for physician services to the physician. I certify that the information given by me in applying for payment of services under Title XVIII of the Social Security Act or for any/all other health insurance is correct. Patient's Signature SSN Date Responsible Party if Patient Unable to Sign Relationship Date Insured Person's Signat,',re .... (If different from patient or if patient is a minor.) Reason patient could not sign. Witness White Copy - Healthcare Billing Canary Copy - Medical Records / Ancillary Departments AD 1825 (5/99) Carlisle Hospital and Health Services CONSENT TO HOSPITAL ADMiSSiON AND MEDICAL TREATMENT Name of ~ttending Physician (s): Date of Admission: iQ~'~C, Time: (AM) (PM) 1. I, (or acting on behalf of) {~(,~{II, ~ ' , suffering from a condition requiring hospital care, hereby Name'Of Patient consent to rendering of such care, which may include routine diagnostic procedures and such medical treatment as the named attending physician(s) or other of the hospital's medical staff consider to be necessary. 2. I understand that the practice of medicine and surgery is not an exact science and that diagnosis and treatment may involve risks of injury, or even death. I acknowledge that no guarantees have been made to me as to the result of examination or treatment during this hospitaliz~ion. 3. I understand that: (A) (B) (C) It is customary, absent emergency or extraordinary circumstances, that no substantial procedures are performed upon a patient unless and until he or she has had an opportunity to discuss them with the physician or other ~ealth professional to the patient's satisfaction; Each patient has the right to consent, or to refuse consent, to any proposed procedure or therapeutic course; and No patient will be involved in any research or experimental procedure without his or her full knowledge and consent. 4. I understand that many of the physicians on the staff of this hospital, including the attending physician(s) named above, are not employees or agents of the hospital but, rather, are independent contractors who have been granted the privilege of using its facilities for the care and treatment of their patients. Further, I realize that among those who attend patients at this hospital ar~ medical, nursing, and other health care personnel in training who, unless requested otherwise, may be present during patient care as a part of their education. Still or motion pictures and closed circuit television monitoring of patient care also may be used for educational purposes or for documentation of the clinical course unless a patient expressly requests otherwise. 5. I release CARLISLE HOSPITAL from all responsibility for all articles which I am retaining or will have with me during my stay at the hospital. I understand this includes clothing, bridgework, false teeth, eyeglasses, jewelry, money, radio, razor or any other item kept in my possession. I understand I may deposit valuables in a safe provided by the hospital; only if this is done will the hospital assume any responsibility for the safekeeping. 6. I hereby acknowledge that I have received written information on the topics of Patient Rights and Advance Directives. {SIGNATURE OF PATIENT} {SIGNATURE OF WIT~ESS} (If patient is unable to consent or is a minor, complete the following:) Patient [is a minor __ years of age] [is unable to consent because]: CLOSEST AVAILABLE RELATIVE} {SIGNATURE 0r ~ITNESS} AD 0315 (10/91) NONE BRONNENELL~ ~NBER A. 21S HILL ST Ca le Hospital 640810 10/28/99 21:1~ CAR (7171486-8775 t2Y F N S 04/24/87 210-66-1363 CONVENIENT CARE/EMERGENCY REGISTRATIOI ,~,;~,,=..;~?~:oo~.~c.,o (717)486-8775 BRO#NENELL, BRENDR K. 21~ HILL ST 16B-&4-328~ MT HOLLY SPRINOS~ PA17065 PA GANE CONNISSION HARRTSBUR6~ PA BRO#NE#ELL~ BRENDa (717)486-8775 18 BLUE CROSS 361 43 YNH168643289 C140650 BLUE CROSS 361 YNH169643289 43 C140650 BR§NNENELL, BRENDA g. O~ BACK PaIN RUONICK~ HONARO L ~ KRETZIN6~HflROLO G --~ PCP KR£TZIN6 NE#VILLE m .... ISOLfiTION ~LEBT N ~RIEF VISIT 26700 GASTRO/HEMO SLIDE 26060 ALL ADDITIONAL CHARGES CLASS I VISIT 26710 KIDDE TOURNIQUET 26048 · · ~'.................... ' CLASS II VISrT 26720 OCL PER FOOT 79670' ! _ _~___ CLASS Ill VISIT 26730 F.S,B.S. 80081 CLASS iV VISIT 26740 TUBE GAUZE PER FOOT 26074 ' .................... ~ ~ ...................... I CLASS V VISIT 26150 ED STAT ESTAT ~ I MINOR SUTURE EDS 01 PULSE OX POXED LMEDIUM SUTURE EDS 02 EXTENDED CHARGE I 26760 t' .................... · MAJOR SUTURE ~ EDS 03 EXTENDED CHARGE II 25770 j INTUBATION EDS 04 I iV SET UP EDS 06 .................. : ....... ' ................... PELVIC EXAM EDS 14 N~TRO SET-UP EDS 16 ~,.~- ~-~,.~,,~,,.~,,.n~'r, cr'nvr'"cu"~=~=" "............................... ,./ ~ 26051 CAST. SCOTCH LONG ARM 25032 ) CAST. SCOTCH SHORT LEG ~0~ ~ CAST. SCOTCH LONG LEG 26034 ~ " · CAST,......~H, PLASTER 26075 /' '~ · .................... ' ................... B/P MON1TOR 26037 I PACER PADS 79064 %* · ,, ] k · TREATMENT iN PROGRESS ON ARRIVAl.: [] CPR Down Time i"l Ai~ay- [] Oral [] Nasal - Size [] Airway, Er~dotracheal o Size [] Airway. Nesob'achea[ - Size [-~ IV. Solution Site. S~ine L~ck Site . , Size Pupila: [] NIA Right - Size Reaction Le~- S2e Reaction = INITIAL NURSING REVIEW: Size Pupil TtME~ [] Monito~ - Rhythm Rate [] Oxygen- [] Mask, [] NC- UMin [] Spinal Immobilization, [] ~ast [] Pressu~eDressing J--JOthe~. Vl~al Activity: E~tremitiee: OD I [] Laceration OS [ [] Deformity ~ Wlm~t Glasses , ~RUGS: " Vital Signs: POX: [] N~A PCX: REASON FOR VIS!T: [] TRAUI~, [] MEDIC_AL [] PSYCHOSOClAIJEMO'[IONAL~. ~ u)z~ - - - - SUBJECTIVE: SAFETY: Are yet. or have you ever bean afraid for your safety in your home? J'lYes r-INo PATIENT PROBLEM: Nursing D~agnosis -- Ai~vay Clearance, Ineffective . C~iac Output, Decreased --j~_ mfort, Alterations in: Communication Impa~recl Coping, Ir, effective Fluid Volume, Alterations Gas Exchange, impaired Hy~eflllermia (Fever) Infec~Jo n, Injury, Potential Knowledge, Deficit MobitRy. Impaired J Noncompliance J Self Care Deficit J Skin Inlegrity, Impaire~ I Thought Process, Alt. in:I Tissue Peffusion, Alt. in: I ., Other [ Clothing Jewelry Other; NURSE'S SIG: NURSE'S SIGNATURE PLAN OF CARE: B Maintain Patient Airway Monitor Cardiova$cula[ Status [] IV [] BP Monitor [] EKG [] Cardiac Monit~ [] Safety Measures [] Restraints I'-] Suicide Precau130ns B Seizure Precautions Side Rails Up [] Comfort Measures [] Pain Control [] Position for Comfor~ [] Prepare for Exam [] Explain Procedures [] Emobonal Support [] Pattent Teaching [] Discharge Instructions [] Other [] Other  Carlisle I-lospi[al and Health Services NURSING DOCUMS:NTA?IOI~ EMERGENCY DEPARTMENT ;ARLISLE H~DSPIT~L . 246 *PARKE .EET CARLISLE~ PA 1'7013.,0310 CON. =.NT CARE/EMERG~MCY REGISTRATION, FOR NURSING ASSESSMENT SEE NURSING DOCUMENTATION SHEET ROS: SH: PMH: · FH: B~,CK PFIIN 05687901 BRONNE#ELL,, RNBER A. ED INTERPRETATION OF: LABS: _.,~ ., , EKG: ' Uf~.,~X.../ ,"' ~, - _ / X-RAY: /9,} TYPE ! AMt' SIGNA'~JRE = MEDICATIONS $/gna~re O IV D/C'd with Catheter intact TREATMENT PROCEDURE 3.1MES IVTOTAL = [] RESP, TREATMENT__ PO TIME ~ TIME TIME ~ TIME [] A~RWAY - TYPE 3'[ME --~ SIZE [] NASOGASTR[C TUBE _ SIZE ~ TIME~ SITE AMT tN __~ AMT OU'[ TOTAL [~ FOLEY SIZE ~ME _ COLOR. [] O~ @ .. VIA TOg'AL _=,,INTAKE: ~ ' OUTPUT: = VITAL SIGNS. I-I ON Bp MONITOR Time Urine TOTAL TOTAL = NOTIFICATION OF: [] HospitaISocial Worker ~1 Family _ [~ Police [] Crisis Intervention, [] Nursing Home~_ ~ Family [] Coroner [] Consu ant D Other, TIMES: EKG ~ CXR ~ LABS DRAWN UA ABG [] PULSE OX NOTES: = EVALUATION AN D DISCHARGE NOTES: ~~ ~ ,, DISCHARGE I~TIONS: ~ ~ DISPOSITION: DISCHARGE: [~'RITTEN INSTRUCTIONS GIVEN '1 AOmitted to: ~] For Observation I T~ansferrecl to: ] Morgue [] litter [] Self [] Carried [~1~amily [~";['mt:)ulatory [] Friend [-I Ambulatory with Assistance t"l Police [] Wheelchair [] ValuatNes J'~ Ambulanca [] Monitored Littm [] Prescnpt;on .,, [] Other .... '" '"-' ~ NURSES SIGNATURE Likesi~be called Eseo? Age ~',, .,~:.. ~,~sent Usual Env~onm~tal (latex, ta~) Exposure rD ~fe~ious Dis~e ~ Yes ~2 No If~, ~ist Immuai~tlnns C~en~ GN/A ~ N/A U N/A :rETANU$ STATUS: Z Within 5 yrs C:5-10 yrs emote thlm l0 yrs Z Unknown ~ N/A CURRENT MEDICATIONS: (Rx, OTC~ Herbs, Vitamins) 1. Med Dose Lasl Dose/Time I0. MEDICATIONS: ~ None U Home C To Pharmacy C @ Bedeia. HABITS: ."~ i3 TOBACCO USE ALCOHOL INTAKE ~ Never Smoked -[] Chew :.'3 Snuff D None ~ Ex Smoker (Date Stopped ) STREET DRUGS [3 Y~s E"~--o Type(s).-, ~'"' u~,,,. MENTAL STATUS: 4t. le 4foCot:.¢~dT,L Mood/Affect: Thought: /, rMemory: Speech: [] Appropriate O Clear/ C~ Intact [] Normal/Clea~ D Blunted/Fla~ Spontaneous C Impaired iD Silent n Defensive ~ Vague/ ~ Recent ~ Talkative ~ Apprehensive Disconnected [] Distant Past 13 Rcpetitive ~ Restless/ ~ Disoriented Combative U Slow to answer Language Barrier.'? Yes No Cc C~ying if, yes, language spoken: c~'Regular ~ Irregular ~ Wheeze r~ Rapid S Full/ iD Weak ~ Shallow E Labored iD Saqdor Bo~ding ?_~R: ~ Deep ~ Relractions Z~Normal Z Flushed Z Dusky [] Cyanosis --' Pale Z Jaundiced ;-'~arm Z Cool ?'Dry D Clarmny ,UNO SOUNDS: Right: ? N/A Lel~: O 01 lOA 0/99) El Nailbeds E~ Circumoral r3Other D Rash E] Ecchymosis ~ Edema ~ Other C Clear ~ Crackles E Rhoochi ~ Diminished ~Wheeze '~ Absent ~ Clear ~ Crackles ~ Rhonchi ~ Diminished ~ Wheeze D Absent PATIE.Wr ASSESSMENT FORM O Carlisle Hospital .Da~e: tc.~?.q~ __Time:_ ~r~ge Status: Mode of Arrival: AcrompanJed ]]y: " - ~od~ I ~ A~ ~ BLS ~ Poli~ ~ Fried ~ofiw II ~buhto~ ~t - F~ilv ~iofi~ III ~ ~¢elcha~ ~ Self U O~' ~ N/A ~ C~ied ~ S~t~r Reaso~ for visit Treatment prior to a~lval ~, - r PAIN: D Denies D N/A Location of Pain__ SeveriLy - 012345678910 ~rmstant ~ Dull C Radiating ilteet Z Sharp ~ Burning Z Other Triage/Signature: f' ft..~,~c,~ Z N,'A PREVIOUS SURGERY: b,t,.r , .: ~- . , ;: N/A implantabie Devices: E Yes ~1 No If yes, explain Other Devices: -- MEDICAL H~TORY/PSYCHIATRIc HISTORY: ~ N/A Z $¢iz~'~ ~ Liver D~sease .2 ~t C H~cnension - Bleed~g Tend~c/~ L~ C C~dia¢ D~e;e C CVA Z Dep~sfon ~ Chest Pain ~ A~itis C ~xiew ~ MI C A~a D T~sfusion G ~cer ~ ~ys~ma Reacfi~ ~ CA C COPD ~ Yes CNo ~ Dis~: U H~e Oxygen C ~cn ~ Cou~ ~ ~spnea ~ FAMILy HISTORY: 7~ Diabetes '~ Card/ac Disease E Hypertension [] CA [] Other Z N/A LEARNING & COMMUNICATION: How do you bee lento? EWrifin r'Vis . ~ . g- ual ~.Rend DDemonstration Whom do we teach? ~ raueet E Other. B .a~ra to [earning? C Yes E No __ Cultural/Religion Needs:E] Yes C No - rought to hospital? GYes~No .Sigh!: U Blind ~ Diminished t~earmg Aid:~Rt[]Ltr-Bo.~ .... s: u t~em E~ Diminished Reviewing RN: __, D Copy to Pharmacy 5N/A PATIENT IDENTIFICATIOlq · ..rusm Hospital -- Emergency Department 246 Parker'St, Carlisle, PA 17013 .- (7~ $5-5500 DISPOSITION SUMMARY BROWI~IEWELL, AMBER 1_.~0' .I0:48pm G 81o Patient: BROWNEWELL, AMBER SS #: CURRENT Acldress: City: Current Ph: Arrival: 10/28/99 10:48 m MD ED: Donna Fehrenbach, D.O. RestPA/NP: ~Obert Weiser, PA-C Dx #1: Thorac c Strain lCD-9 #1:847.1 Zip: _ Disch: 10/28/99 10:54pm PMD: PMD Ph: Age/DOB: .. Medical Record: 640810 Disposition: Follow-up: KRETZING,HAROLD G ~50 WALNUT BOTTOM ROAD CARLISLE PA FlU MD PI~: 7172431515 FlU D/T: NEXT WEEK Other Instr: MOIST HEAT F R 20 MINUTES 4-5 TIMES A DAY. NO PHYSICAL ACTIVITY. RETURN TO THE ER IF SYMPTOMS WORSEN FOLLOWW;TH YO~EEK IF NO IMPROVEMENT. CONTIN E THE ADVIL AS DIRECTED FOR PAIN. May return to work/school: 10-29-99 Restrictions: NO GYM CLASS FOR 1 WEEK, · ~Y SIGNATURE BELOW INDICATES: I have received and understood the oral instructions regarding my current ,T~edica~ problem. . I will arrange follow*up care as instructed above. I acknowledge receipt of the written instructions as outlined on this and ~.~evious page(s)~ will read and review these instructions. .,-,, atient (or Legal,43~Jardlan} S~gnature Staf~ (W~tne~'*'~gnature JOINDER I, Brenda Brownewell, individually and as parent and natural guardian of Amber Brownewell, a minor, hereby state that I have read the foregoing Petition and reviewed it with my attorney, Scott B. Cooper, Esquire, and that I understand, agree and approve the contents thereof and join in the Petition. B~enda Bro~;~rell, as Parent and Natural Guardian of Amber Brownewell CONTINGENT FEE AGREEMENT THIS AGREEMENT entered into the ~ day of~/~?~/~£% 1999, by and between SCH~4IDT/ RONCA & KRAMER, P,C. and Brenda Brownewell, hereinafter referred to as "Client." WITNESSETH: The law firm of sCHMIDT, RONCA & KRAMER, P.C., will act as Client's attorney in negotiating for a settlement, and in bringing a claim against Allan J. Stutenroth or anyone else arising out of an accident which occurred on October 19, 1999, at the intersection of South Hanover and Pomfret Streets, Cumberland County, Pen~'sylvania. In addition, SCHMIDT, RONCA & KRAMER, P.C., will pursue all claims for underinsured or uninsured motorist benefits to which the Client may be entitled under his/her insurance policy. In return, the Client will: 1. Promptly supply accurate information, as requested by sCHMIDT, RONCA & KRAMER, P.C., and cooperate fully, including making myself available for meetings with my attorney and for legal proceedings. Client promises all information supplied will be truthful and accurate. 2. (a) In any claim brought on Client's behalf, to pay scHMIDT, RONCA & KRAMER, P.C., for its services an amount equal to 30% of any recovery made prior to fililng suit; 33-1/3% of any recovery made after filing suit and before trial starts; and 40% of any recovery made after a trial starts. In any matter submitted to arbitration, suit is filed when the arbitrators are appointed or when a Petition to Appoint Arbitrators is filed, In any matter submitted to arbitration, whichever first occurs. trial starts the first day the arbitrators have convened to hear testimony. In the event that any settlement is made on a structured or deferred payment basis, SCHMIDT, RONCA & KRAMER, P.C., shall be entitled to receive their percentage based on the cost of the structured settlement, paid as a lump sum at the time of settlement- (b) I agree I will not settle or negotiate the above claim or any proceedings based thereon. (c) If Client terminates this Agreement before recovery, Client agrees that SCHMIDT, RONCA & KRAMER, P.C., shall be entitled to a fee based upon work done and benefit conferred. 3. To reimburse sCHMIDT, RONCA & KRAMER, P.C., out of any recovery, in addition to attorney's fees, all costs and expenses incurred on Client's behalf in order to make the claim. Ail such costs and expenses will be advanced by sCHMIDT, RONCA & KRAMER, P.C., as they are incurred. Such costs and expenses include, but are not limited to, filing fees, cost of medical records, copying costs, fax costs, long distance telephone costs, expert witness fees and sheriff's service costs. In the event there is no recovery, the client will not be responsible for any costs or interest charges. Costs will be repaid to sCHMIDT, RoNCA & KRAMER, P.C., of any funds or property collected either by settlement or out 2 judgment. 4. Claims are separate items. SCHI~IDT, process these claims. A separate agreement will have to be entered into for fees if a major dispute occurs filing of suit for these benefits. The client has read and does understand this Agreement. Signed the day and year set forth above. for medical benefits and income loss benefits RONCA & KPJtMER, P.C., will help you requiring the WITNESS: ~~rdwnewel 1 Individually and as Parent Md Natural Guardian of Amber B~ ewell, a Minor Approved: ./ ~ / Sc~IDT, ~ONCA K~R, P.C. have received a copy of this n~nt Fee Agreement. i , /' ~nftiais 3 FiLE No.235 01/14 '04 16:33 ID:LAW OFC BF ANNA WALDHERR FAX: PAGE REI, EA~.~;~ OF Al,l, CLAI M~4_ FOR AND IN CON,'.IlI)I';I~,ATI()N OF tile pt~yrnel~t to tv{ ol'tht~ sum of¢)n~ 'l'housaIt~ ~!rs fSI .O00J)Ol, and other good and vlduablc consideration, we, Bfvllda Browne~oll and ~ Iso~bcrm o~rcnt~ and ~u~rdim~s 9lAmber Brow~wcll. n ~, being ofluwl~d age, have relearned ~tnd discharged, and by Ih~sc prc~nts do Ibr said minor, her helm, vxccutors, administruters and assigns, release, acquit and Ibr~wcr discharge &I,I,AN J. KI'trI'I",NIt()TII ~NSUItANCI( k'.OMPANIES arm ~tlly and all other p,~rsons, firms and corporations or and l~t)m any and all aclions, causes ol'action, claims or demands Ibr damages, c{~st8, h~ss o1' usc, loss of services, expenses, COlllpgllStlti(m, uollseqtlc~tiaJ damage or any other thing whatsoever m~ uuCOtlllt ol~ or ill ttny way gr¢lWillg out o[~ any alld all ktlown ulld tlllkllOWll pcl'scJiiaJ i~tjurics death and pr~pcrty damage resulting or le result Ihmt tm occurrence or accident that happened on ()r ahmlt thc 19"' dtw ol'()gLt}~cr 1999 at or near tl~inlcrscction ~)1' South Hanover Street trod I)oml¥ct Strict, lIom~lgll o('Carlislc. Cumb~r~!~ County. Pennsylvania, said incident b¢inalh~ ~~. ~qlC ~ ~ ~l'e~tl BrowncwclL individually and as parent nalurat mmrdian nl'Am~'~ Brownewell. n minor v. Allen J. Stutenroth. Docket No. 01-5384. Civil Term, Cumh~rlmld (~. Court ol'Common Pleas. I)cnnsvlvania, We hereby acknowledge and assume all risk, chance or ht~ard that the said i~xiuries or damag~ may he or b~col~l¢ permanent, progressive, greater, nr more extensive thai1 is ilow known, anticipated (}r ~xpccted. No promise er inducement which b not herein expressed h~ts hcun made to us, and in executing this r~lcase we do not rely upon ~my statement or representation tmtdc by uny persm~, firm or corporation, hereby released, or any tlg~nt. doctor or any other persoll rcpl'CS¢llthlg them ()1' any oF lhclll, CollCCl'llhlg thc ilatare, extent t)r duration oCsaid damages or losses or thc legal liability klL~ No.ZYb 01×14 '04 16:33 ID:LAW OFC OF ANNA WALDHERR FAX: PAgE 2 We Llndel'StJiild thai this settlemenL is the c{)tnprm3~isu ot'z~, doubtt'~ll and disputed and tirol thc imymm~t is not Lo bc cm~strucd ~s aa admission ot*liability on tl~c part of thc pectins, firms and cm'porations hereby released by whom liability is expressly denied. Wc lhrthcr that this release shall not be pleaded by us as a bar to any claim or suit. This release contains the I qN'l'IRl'; A(iREEM1 ~N'I' ~tween thc parties beretu, and the terms of this release arc contractual and not a mere recital. We t~lrtber state that we have camt[dly read thc Ibrcgoing release and know thc themot~ and we sign the same as oar own I~e act. ,2004. WITNESS our hands and seals this .... day ~1' . WI 1NI.SSI,S CAtJTI()N! I,IEAI) Bt';I"ORE SIONINCi {address) Brenda Browllewell Mark l.~m~berg .(SEA1.) __(SEAl ,) (address) CERTIFICATE OF SERVICE_ AND NOW, this day of April, 2004, I, Scott B. Cooper, Esquire, counsel for the Plaintiff, hereby certify that I have, this day, served a copy of the foregoing Petition by serving a copy of the same in the United States mail, postage prepaid, at Harrisburg, Pennsylvania, addressed to: John C. Swartz, Jr. Wagenfeld Levine 2 Penn Center Plaza, Suite 1120 1500 John F. Kennedy Blvd. Philadelphia, PA 19102 Respectfully submitted, SCHMIDT, ROI~ICA, & KRAMER, P.C. DATE: ocott t3. Cooper ~ I.D. #70242 209 State Street Harrisburg, PA 17101 (717) 232-6300 Attorney for Plaintiffs / AP 2OO4 IN THE COURT OF COMMON PLEA,~ CUMBERLAND COUNTY~ PENNSYLVANIA Brenda Brownewell, individually and as parent and natural guardian of Amber Brownewell, a minor Allen Stutenroth Plaintiffs Defendant. Civil Action - Law No: 01-5384 QRDER AND NOW, this ~ day of /~. ~,; l , 2004, it is hereby ORDERED AND DECREED as follows: 1. That the settlement terms as set forth in the foregoing petition on behalf of the minor, Amber Brownewell, are approved. 2. The court approves this settlement in the lump sum of ONE THOUSAND DOLLARS ($1,000.00} to be distributed as follows: To Brenda Brownewell, As the Parent and Natural Guardian Of Amber Brownewell, a Minor $ 1,000.00 To t alL_,~L!_~)O0.00 3. That the settlement be paid directly to the Petitioner on behalf of her minor daughter to invest said sums in either Certificates of Deposit and/or Savings Account at Members 1st Federal Credit Union, 5000 Louise Drive, Mechanicsburg, PA 17055, as such sums not to exceed those insured by F.D.I.C. 4. That said money invested and placed into a Savings Account and/or Certificate of Deposit shall not be deemed withdrawn, negotiated, cashed, or alienated in any way until the Petitioner's minor's eighteenth (18) birthday which is April 24, 2005, except by Order of this Court. 5. The law firm of Schmidt, Ronca, & Kraraer, P.C., shall oversee the directives set forth in the preceding paragraph. 6. The Petitioner is directed to execute the: Release attached to the Petition as Exhibit "E'. By The Court: